Every finding on record at Baptist Health Home Care In, LLC

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102. Survey Dates: 3/24/2022 - 4/1/2022 At this Emergency Preparedness survey, Baptist Health Home Care Floyd, was found not to be in compliance with Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, 42 CFR 484.102. QR Completed 4/13/2022 A4

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to update the policy for emergency preparedness plan every two years for 1 of 1 agency. Findings include: 1. A revised 9/3/2019 policy titled Home Health Emergency Preparedness Plan [2.1] was provided by the Alternate Administrator (AA) on 3/28/2022 at 11:15 a.m. The policy indicated, but was not limited to, "PURPOSE To describe the Baptist Health Home Care approach to responding to internal and external emergencies that would suddenly and significantly affect services, plans for patients or the ability to provide such services…". 2. A review of the Emergency Preparedness Plan indicated since the last revision in 2019, the policy had not been updated. 3. An interview was conducted with the Administrator and Office Manager Q on 4/1/2022 at 8:45 a.m. It was indicated the policy was currently being updated and revised with all other policies by the hospital who did it every 3 years.

This visit was for Federal Recertification, State Re-Licensure, and Emergency Preparedness survey. Survey Dates: 3/24, 3/25, 3/28, 3/29, 3/30, 3/31 and 4/1 of 2022 Partially Extended Survey Announced 3/28/2022 at 9:30 a.m. These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, the agency failed to maintain an updated list of all medications their patients were prescribed for 3 of 7 home visits. (Patient 6, 9 and 16) Findings include: 1. A 9/30/2019 last revised document titled "Documentation in the Medical Record" was provided by the office manager on 3/24/2022 at 2:41 p.m. The document indicated but was not limited to; "All prescribed medications, over-the-counter (OTC) medications and home remedies will be documented on the medication profile as well as: date medication prescribed, dose, frequency and route." and "The nurse or therapist will add all new/changed medication(s) to the medication profile. Discontinued (D/C) medications will be documented and dated. The medication profile will be reviewed every home visit and updated as changed occur." 2. During a home visit on 3/30/2022 at 1:00 p.m. patient #6's medications observed in the home were compared to the medications listed on the patient medication profile and plan of care. Four (4) medications were not listed on the medication profile and were in the home included: Metolazone (used to treat high blood pressure or edema) 2.5 milligrams (mg) take 1 tablet three times daily. Bumetanide (used to treat edema) 1mg take 1 tablet daily on Sunday, Tuesday, Thursday, and Saturday and take twice daily on Monday, Wednesday and Friday. Amlodipine (used to treat high blood pressure) 2.5 mg take 1 tablet daily. Hydrocodone/APAP 7.5 mg/325 mg (used to treat pain) take 1 tablet every 6 hours as needed for pain. 3. During a home visit on 3/30/2022 at 2:00 p.m. patient #9's medications observed in the home were compared to the medications listed on the patient medication profile and plan of care. One (1) medication, prednisone (used to treat inflammation) 10 mg take one daily, was in the home and not listed on the plan of care or medication profile. Patient stated they were taking it as needed for pain and swelling in the right leg. 4. During a home visit on 3/31/2022 at 10:30 a.m. patient #16's medications observed in the home were compared to the medications listed on the patient medication profile and plan of care. One (1) medication had been discontinued prior to this visit and one (1) medication was listed incorrectly on the medication profile. Patient #16's plan of care had orders for oxycodone (used to treat pain) 5 mg immediate release tablets 1-2 tablets every 4 hours as needed for moderate pain. The patient stated they were no longer taking this medication since 11/2021. Patient #16's medication profile stated furosemide (used to treat edema) 80 mg one table twice daily. Medication in home observed was furosemide 40 mg 1 tablet daily and was correct dose per the patient. 410 IAC 17-14-1(a)(1)(B)

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a current plan of care was provided to the patient for 7 of 7 home visits with the potential to affect all patients. (Patients 4, 5, 6, 8, 9, 10, and 16) Findings include: 1. A revised 4/1/2020 policy titled Patient Admission Criteria and Admission Information [9.2] was provided by the Alternate Administrator (AA) C on 4/1/2022 at 10:12 a.m. The policy indicated but was not limited to, "PURPOSE To establish criteria for admission of patients to the Agency and to provide patients with accurate information to make informed decisions regarding care or services…" 2. During a home visit on 3/28/2022 at 1:41 p.m. with patient 4, the agency admission home folder was reviewed. The folder evidenced no Plan of Care (POC) within. The Alternate Administrator (AA) C, who was present on the visit, indicated a POC should be in the folder or at least in the home. The agency failed to ensure a current plan of care was provided to the patient. 3. During a home visit on 3/29/2022 at 1:30 p.m. with patient 5, the agency admission home folder was reviewed. The folder evidenced a POC but was deficient of all required elements. The agency failed to ensure a current plan of care was provided to the patient. 4. During a home visit on 3/30/2022 at 1:00 p.m. with patient 6, the agency admission home folder was reviewed. The folder evidenced a POC but was deficient of all required elements. The agency failed to ensure a current plan of care was provided to the patient. 5. During a home visit on 3/29/2022 at 11:30 a.m. with patient 8, the agency admission home folder was reviewed, the agency admission folder was reviewed. The folder evidenced a POC but was deficient of all required elements. The agency failed to ensure a current plan of care was provided to the patient. 6. During a home visit on 3/30/2022 at 2:00 p.m. with patient 9, the agency admission home folder was reviewed. The folder evidenced no Plan of Care (POC) within. AA C, who was present on the visit, indicated a POC should be in the folder or at least in the home. The agency failed to ensure a current plan of care was provided to the patient. 7. During a home visit on 3/30/2022 at 11:30 a.m. with patient 10, the agency admission home folder was reviewed. The folder evidenced a POC but was deficient of all required elements. The agency failed to ensure a current plan of care was provided to the patient. 8. During a home visit on 3/31/2022 at 10:30 a.m. with patient 16, the agency admission home folder was reviewed. The folder evidenced no Plan of Care (POC) within. The agency failed to ensure a current plan of care was provided to the patient. 9. During an interview on 3/29/22 at 2:00 p.m., AA C indicated the form named “Coordinated Plan of Care” was used in place of the printed plan of care because it was filled out in “plain language” for the patient.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide a written visit schedule for 3 of 7 home visits. (Patients 4, 9, and16) Findings include: 1. A revised 4/1/2020 policy titled Patient Admission Criteria and Admission Information [9.2] Policy was provided by Alternate Administrator C on 4/1/2022 at 10:12 a.m. The policy indicted, but was not limited to, “ADMISSION/START OF CARE [SOC] 10. Provide the patient with a written planned visit schedule...” 2. During a home visit on 3/28/2022 at 1:41 p.m. with patient 4, the admission folder was reviewed. The folder failed to evidence a visit schedule showing what days and times services would be provided. RN H stated the schedule was set and the patient knew what it was but there was no written version of it in the home. 3. During a home visit on 3/30/2022 at 2:00 p.m. with patient 9, the admission folder was reviewed. The folder failed to evidence a visit schedule showing what days and times services would be provided. The patient stated they always received a phone call to set up a time for the visit. 4. During a home visit on 3/31/2022 at 10:30 a.m. with patient 16 the admission folder was reviewed. The folder failed to evidence a visit schedule showing what days and times services would be provided. The patient stated they always received a phone call the morning of the visit to set up a time.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator reported directly to the Governing Body without the use of intermediaries for 1 of 1 home health agency. Findings include: An undated organizational chart was provided by Office Manager (OM) Q on 3/24/2022 at 1:44 a.m. The organizational chart showed the administrator reporting directly to the System Vice President for Home Care, who is not an employee of the Baptist Health Home Care and is not on the governing body. Upon review, Alternate Administrator (AA) C provided governing body meeting minutes from 12/9/2019 and 3/22/2021. Both documents indicated the Safety, Quality & Patient Experience Committee for [Entity 1] Board of Directors received and reviewed the Annual Report of Baptist Health Home Care. Each resolution was accepted on the day received and reviewed and then signed off on by the Chief Legal Officer with [Entity 1] in [Name of City/State]. An undated Organizational Chart for [Entity 1] was provided by AA C on 3/28/2022 at 11:10 a.m. Upon review this chart shows Baptist Health Floyd as an Unincorporated Operating Division within [Entity 1] but does not show the link between the administrator at the Baptist Health Home Care and the [Entity 1] Board of Directors. A revised December 8, 2020 Action of the Baptist Health Board of Directors BYLAWS for [Entity 1] , INC was provided by AA C on 3/28/2022 at 11:10 p.m. Upon review there was no clear delineation of where Baptist Health Home Care falls within the [Entity 1] or what the reporting structure should be with the [Entity 1] Board of directors. An interview was conducted with Administrator on 3/28/2022 at 9:30 a.m. The Administrator indicated the governing body is above [Name of Physician], Chief Health Integration Officer President. The administrator indicated the directors for each Home Care entity meet to update the Vice President of Home Care who reports to the Chief Health Integration Officer and [Name of Hospital] Regional President who then reports to the [Entity 1] Board of Directors. The administrator was unable to name the Board of Directors or the governing body and did not provide the list as requested. 410 IAC 17-12-1(b)